U.S. Department of Health and Human Services (HHS) OMB Control # 0920-0932
Centers for Disease Control and Prevention (CDC) Expiration Date XX/XX/XXXX
Healthcare Provider Questions
Q1. How much do you like the message <insert main tagline here> for your patients?
0=Do not like it at all, 10=Like it extremely well
Q2. Overall, how well do the following phrases describe the ad above?
0=Does not describe at all, 10=Describes perfectly
Easy for patients to understand
Provides appropriate advice to patients
Is relevant to my patients
Q3. For each of the following statements below, how effective do you think the ad shown above
is in…
0=Not effective at all, 10=Extremely effective
Motivating your patients not to travel when they have the flu
Making your patients take the issue of traveling with the flu more seriously
Making
your patients think differently than they have in the past about
traveling when
they have the flu
Q5. Thinking about the ad shown above, please indicate how much you agree or disagree with each of the following statements.
Across top: Disagree Disagree Neither Agree Agree Agree
Completely Somewhat Nor Disagree Somewhat Completely
1 2 3 4 5
This ad…
Will get my -patients’ attention
Tells my patients how to prevent the flu during travel
Motivates my patients to travel only when they are feeling well
Shows patients that CDC is concerned about preventing flu during travel
Q6. Based on the message “<insert tagline>,” how willing would you be to disburse these materials directly to your patients?
0=Not at all willing, 10=Very willing
<if respondent chooses 0-5 for willingness, then ask Q6 below>
Q7. What format of materials would be helpful to use with your patients? (Rank by preference)
Postcard
Brochure
Flyer
Poster
Video
E-mail template
Materials to post on website
Other: __________________
I would not use these materials.
Q8. Which of the following channels do you feel is the best for disbursing travel health information to patients?
Primary care physician
Other health-care provider
Travel medicine clinic
Family and friends
Travel agents or tour operators
Health-related websites such as WebMD
CDC website
Other websites (please specify) _____________________
Books
Other (please specify) __________________________
Q9.
How helpful do you feel this type of public information campaign
from the CDC is to the
traveling public?
0=Not at helpful, 10=Very helpful
<Display all concepts together on one page with “mouse-over” magnification for Q9-10>
0=Not at all willing, 10=Very willing
Q13. In the previous question you indicated some reluctance to disburse the campaign material shown above. Please tell us both:
Why would you be reluctant to share the material? (open ended) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
How can we improve it? (open ended)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Public reporting burden of this collection of information is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor a project, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-0932.
File Type | application/msword |
File Title | Healthcare Provider Questions |
Author | wernerk |
Last Modified By | SYSTEM |
File Modified | 2018-03-21 |
File Created | 2018-03-21 |